Pediatric Bone Marrow Transplant Patients Research Articles

Quality of life in parents of Turkish and Syrian pediatric bone marrow transplant and oncology patients.

The success of the treatment depends on the well-being of the parents in pediatric cancer patients. In addition, migrants need to deal with the consequences of war. Our purpose was to compare the HRQoL of parents of Syrian and Turkish children followed in our bone marrow transplant and oncology units. One hundred SF 36 questionnaires, fifty from each group were collected between October 2019 and March 2020 in this cross-sectional study. Demographic characteristics of the patients (sex, age, cancer type, presence of relapse, duration of follow-up) and education level of parents were recorded. Analyses were performed using IBM SPSS Statistics version 20.0. Turkish parents reported better results in physical functioning, emotional well-being, physical pain, general health, and physical health composite score (P < 0.05). There were more fathers in the Syrian group and education status was significant between the two groups (P = 0.01, P = 0.001, respectively). There was no correlation between QoL and education levels in the Turkish group. In Syrian parents, pain score was high in middle school graduates (P = 0.043). In the presence of relapse, although the physical function score decreased, the physical role function score increased in Turkish parents (P = 0.0035, P = 0.005, respectively). Syrian parents' emotional role function and energy/fatigue score were both increased when children had relapses (P = 0.027for both). Migration is a complex issue. Turkish parents were better in physical functioning, emotional well-being, physical pain, general health, and physical health composite score. Screening for parental burden, assisting them to find appropriate support services is essential in improving the health and QoL of both our patients and their parents.

176 - Outcomes of Pediatric Bone Marrow Transplant Patients Receiving Palifermin with Melphalan-Based Conditioning Regimens

176 - Outcomes of Pediatric Bone Marrow Transplant Patients Receiving Palifermin with Melphalan-Based Conditioning Regimens

A Novel Oncodental Collaborative Team: Integrating Expertise for Central Line-Associated Bloodstream Infection Prevention in Pediatric Oncology Patients.

Pediatric oncology and bone marrow transplant patients are at high risk of infection, and limitations to dental expertise among medical providers render patients vulnerable to central line-associated bloodstream infections from oral pathogens. Traditionally, oral health maintenance relied on patients and bedside nurses; however, routine methods are often suboptimal to prevent central line-associated bloodstream infection in high-risk patients. Limited overlap of medical and dental expertise, and limited dental resources in typical oncology units, prevent optimal oral care for children with cancer, requiring novel solutions to better integrate specialties. Here, we outline the creation of a novel Pediatric oncodental team to address oral-systemic infection prevention strategies for high-risk patients. Our oncology and dental teams created a systematic approach for increasing oral surveillance and treatment in select high-risk patients. Supervised pediatric dental residents participated in scheduled oncology rounds, and a permanent oral health educator with a background in dental hygiene was also hired as a dedicated dental professional within our oncology department. Our pediatric oncodental team aims to sustain optimal oral complication prevention strategies to reduce the risk of infection, provide education on the significance of the oral-systemic link in cancer care, and improve access and continuity of care.

Evaluation of the risk factors for BK virus-associated hemorrhagic cystitis in pediatric bone marrow transplantation patients: Does post-transplantation cyclophosphamide increase the frequency?

BKV-HC is one of the most significant complications of HSCT. This retrospective study aimed to determine the frequency of BKV-HC in pediatric patients undergoing HSCT, detect the associated risk factors for the development of BKV-HC, and explore the effects of post-transplantation Cy use. Three hundred twenty-seven patients (girls: 121, boys: 206) were analyzed according to sex, conditioning regimen, transplantation type, donor relatedness, stem cell source, the presence and grade of aGVHD, CMV co-existence, and Cy use. Multivariate analysis confirmed the prognostic importance of age (OR: 4.865), TBI use, the presence of aGVHD (OR: 2.794), CMV coinfection (OR: 2.261), and Cy use (OR: 27.353). A statistically significant difference was found between the mean BKV-HC follow-up times compared with post-transplantation Cy intake (p < .001). The BKV-HC rate increased as the number of risk factors of the patient increased. BKV-HC is an essential complication of HSCT primarily associated with Cy use, the presence of aGVHD, and donor relatedness. The present study shows that the use of Cy in the post-transplantation period further increases BKV-HC risk in pediatric patients, regardless of dose.

Chlorhexidine gluconate (CHG) foam improves adherence, satisfaction, and maintains central line associated infection rates compared to CHG wipes in pediatric hematology-oncology and bone marrow transplant patients

CHG-based hygiene methods are often a component of daily hygiene bundles to prevent central line-associated blood stream infections (CLABSIs) in pediatric hematology-oncology patients; however, adherence with 2% CHG wipes was inconsistent within our institution, risking infection for immunocompromised patients. A new 4% CHG foam method offers an alternative and is applied while bathing, as opposed to wipes used 1 h after bathing. An initial cohort of 24 high-risk oncology and bone marrow transplant (BMT) patients agreed to use 4% CHG foam in place of wipes, and then answered surveys to describe their experiences. Ninety-two percent preferred foam over wipes and were more likely to use the foam moving forward. CHG foam was then made available as an option to all patients in need of central line care upon admission to the hospital. Hygiene bundles in the electronic medical record were reviewed to measure baseline adherence rates. Random audits by nursing administration prospectively assessed CHG adherence. CLABSI data were collected prospectively with routine quality metric reports. Results were analyzed using run charts and u-charts, respectively. Hematology-Oncology unit adherence rates remained at a higher rate of adherence, and BMT unit adherence rates increased from an average of 55%–81.6% (p < 0.001). Primary CLABSIs remained rare events (average <1/1000 CVL days). On cost analysis, utilizing CHG foam results in an annual savings estimate of $40,000 for a 24-bed unit. In conclusion, 4% CHG foam provides a cost-effective and patient-preferred option for daily hygiene that maintains CLABSI preventative efforts.

Standardization of Fertility Preservation Discussion Among Pediatric Oncology and Bone Marrow Transplant Patients: A Single Institution Experience.

Purpose: Infertility is an impactful late effect of cancer therapy. Options for fertility preservation exist, however, barriers remain. Within our division, we lacked a standard approach to discussing fertility preservation. Methods: During the time period of 2014-2020, a fertility preservation program was developed with program improvements implemented over time and provider comfort with fertility identified and addressed through educational intervention. To evaluate how our improvements affected frequency of documented reproductive health discussions, 474 pubertal pediatric patients with new oncological diagnoses were reviewed. Descriptive analysis of sociodemographic determinants was performed. Results: One hundred seventy-five patients met inclusion criteria. Racial/ethnic composition was similar in those receiving and not receiving a fertility consult. Although 19.3% of Caucasians pursued fertility preservation, none of the eight African Americans or five Hispanic females did. Division feedback identified a lack of knowledge regarding available fertility preservation options and diagnoses that should prompt this conversation as barriers to the consulting fertility preservation team. Pre- and posteducation assessments demonstrated increased comfort in discussing fertility preservation and knowledge regarding diagnoses at higher risk of infertility. Integration of a standardized fertility preservation process and addressing barriers identified led to a 33.6% increase in fertility discussions. Conclusion: The establishment of a fertility preservation process and team and division-wide education has led to improvement in rates of fertility discussion in pediatric and adolescent and young adult cancer patients. Similar to young adult data, our data suggest that some racial health disparities may exist in the utilization of fertility preservation in the pediatric oncology population.

Is it safe and efficacious to remove central lines in pediatric bone marrow transplant patients with platelets less than 20,000/μl?

BackgroundPatients with tunneled central venous lines (CVL) may develop bloodstream infections which at times are difficult to control without line removal. Concomitant severe thrombocytopenia with platelet transfusion refractoriness is often considered a major contraindication to any procedure involving a major blood vessel. There is very little literature on the clinical risks of tunneled central line removal in febrile pancytopenia patients.ProcedureWe analyzed complications and outcomes in all our patients, a total of 52, who underwent CVL removal with platelets <20,000/μl.ResultsCVL removal was done on a median day of 17.5 with 47 of the 52 patients never having achieved platelets engraftment prior to line removal. No bleeding episodes or unplanned transfusions could be associated with CVL removal. No other complications were also reported. All patients had time to hemostasis within 5 min of catheter removal. Removal of CVL under local anesthesia remained complication‐free even at platelet counts less than 20,000/ul. A total of 31 patients were febrile at the time of CVL removal, of which 17 became afebrile within 2 days. We found no difference in defervescence when comparing those whose antibiotic therapy was changed/escalated versus those in whom it was not.ConclusionOur findings suggest that central lines can be safely removed with platelet counts less than 20,000/ul and that this may result in enhanced bloodstream infection control. This might be particularly relevant to neutropenic patients in this day and age of multidrug‐resistant organism emergence and paucity of new effective antibiotics.

Effect of granulocytes infusion in pediatric neutropenic and bone marrow transplant patient

Effect of granulocytes infusion in pediatric neutropenic and bone marrow transplant patient

Impact of FilmArray™ Respiratory Panel testing on the clinical management of pediatric bone marrow transplant patients.

Viral respiratory tract infections cause significant morbidity in bone marrow transplant (BMT) patients. Speed and sensitivity of the FilmArray™ Respiratory Panel (FA-RP) can improve care but may prompt inappropriate testing. Studies describing FA-RP use in pediatric BMT patients are limited; we investigated FA-RP use, results, and clinical management to evaluate clinical significance of testing in pediatric BMT patients. Retrospective analysis of 671 respiratory specimens from 204 unique BMT patients between 01/01/2016 and 01/01/2019 was performed. Age, underlying diagnoses, FA-RP result, reason for FA-RP, and symptoms were abstracted. FA-RP impact on antimicrobial management, scheduled procedures, infection control measures, and hospital admission/discharge were investigated. Impacts of repeat testing were evaluated. Two hundred sixty-nine out of 671 specimens (40%) tested positive; human rhinovirus/enterovirus (hRV/hEV) was the most common (161/269, 60%). The primary reason for FA-RP was URI symptoms (402/671, 60%) with 54% testing positive. One hundred twenty-two out of 671 (18.2%) specimens were from asymptomatic patients; 14 (11.4%) tested positive. FA-RP informed antiviral initiation in 7/19 (36.8%), 7/8 (87.5%), and 5/30 (16.7%) of RSV, influenza, and human parainfluenza cases, respectively. In 11 cases, FA-RP informed azithromycin and ceftriaxone initiation, continuation, or discontinuation. BMT was delayed for three positives (two RSV, one hRV/hEV). In 22 instances, negative FA-RP cleared patients for BMT. In 70% of cases, repeats offered no new clinical information; all negative-to-positive cases had new or worsening respiratory symptoms. FA-RP was ordered on symptomatic and asymptomatic patients, provided rapid diagnosis in > 50% of symptomatic patients, and informed infection control measures for all inpatients and antiviral initiation in > 80% of influenza cases.

Optimizing Iron Overload Screening in a Pediatric Center for Cancer and Blood Disorders

Background: Packed red blood cell (PRBC) transfusions are common in the management of pediatric hematology, oncology, and bone marrow transplant (HOB) patients, and can lead to accumulation of excess iron that the body is unable to excrete. Increased exposure can lead to the development of iron overload (IO), which results in toxic effects on the liver, heart, and endocrine organs. Treatment can reduce the body's iron burden and improve outcomes. Previous studies observed that patients who received >10 PRBC transfusions or had an elevated serum ferritin were at a higher risk of IO. Unfortunately, published guidelines for IO screening only exist for a minority of HOB patient subtypes (thalassemia, sickle cell, and bone marrow transplant). The Children's Hospital Colorado Center for Cancer and Blood Disorders (CCBD) lacked a system to track transfusion frequency and a standardized guideline to adequately screen for IO, which made this a prime process improvement opportunity.Objective: Improve screening for IO by increasing the percentage of CCBD patients with >10 PRBC transfusions who have received a serum ferritin to >75%.Methods: All patients seen in CCBD clinics in 2015 were evaluated for the total number of transfusions received prior to 2016 and whether additional workup for IO was obtained. With this baseline data, a multidisciplinary working group created 3 interventions to improve identification and screening of IO.First, initial screening recommendations were integrated into the electronic health record (EHR) to alert providers when a patient has had >10 PRBC transfusions, prompting them to order a screening serum ferritin. Second, after a review of existing literature and discussion with local content experts, a risk-based screening algorithm was created and linked to the EHR alert to guide further testing. The algorithm recommends obtaining a liver and cardiac MRI for iron content in patients with a ferritin persistently >500 ng/mL. It also provides recommendations for phlebotomy or chelation in patients with liver and/or cardiac IO based on MRI findings. Third, providers were educated on IO screening and treatment. Data on screening practices will be collected and analyzed on an ongoing basis to track the response to the interventions and modify our approach, if needed.Results: Analysis of preliminary data from 2015 demonstrates that 19% of patients seen in CCBD clinics had >10 transfusions (192/1006). The percentage of patients with >10 transfusions that had a serum ferritin drawn was 53% (101/192). However, only 45% of patients had a ferritin obtained after receiving 10 transfusions (86/192). The most common sub-group was patients with oncology diagnoses (94/192, 49%), but only 14% (13/94) of oncology patients had a screening ferritin after 10 transfusions. In contrast, 90% (26/29) of hematology and 68% (47/69) of bone marrow transplant (BMT) patients had a screening ferritin. The mean time to obtaining a ferritin after 10 transfusions was 392 days. When evaluating all patients who had a ferritin sent, the value was >500 ng/ml in 80% (81/101) and >1000 ng/ml in 60% (61/101). Despite having a ferritin >500 ng/ml, only 46% (37/81) of patients received additional testing with a cardiac and/or liver MRI for iron content. There is ongoing collection and analysis of data evaluating improvements in screening practices since the EHR alert, risk based screening algorithm, and staff education began.Conclusions: Relatively few CCBD patients at risk for IO received initial screening, and even fewer had additional testing to evaluate for organ based IO. One reason that fewer oncology patients were screened may be the lack of an available guideline for IO screening. In contrast, available screening recommendations for sickle cell, thalassemia, and BMT patients may explain the increased frequency of screening in hematology and BMT patients. However, even patients who were screened and had an elevated ferritin did not uniformly receive additional testing with a cardiac and/or liver MRI. The goal of this project is to establish a baseline percentage of high-risk patients screened for IO, and then increase this level using a CCBD-wide standardized approach of staff education and EHR lab test prompts according to a standardized algorithm. As a result of the proposed interventions patents may be diagnosed earlier and subsequently treated when the disease burden is lower. DisclosuresNo relevant conflicts of interest to declare.

Standardization of fertility preservation discussion amongst pediatric oncology and bone marrow transplant patients.

10051 Background: As treatment for pediatric malignancies improves long term survival, physicians are shifting focus to late effects of therapy such as infertility. Currently, options for fertility preservation include cryopreservation of mature oocytes, sperm, and gonadal tissue, although barriers remain present. Within our division, we lacked a standard approach to discussing fertility preservation options. Methods: Records from 474 pediatric patients with new oncologic diagnoses at CMH from 2014-2020 were retrospectively reviewed. We evaluated the frequency that reproductive health discussions were documented in pubertal males and females requiring chemotherapy or radiation treatment. We implemented a standard fertility preservation note and patient handouts, then surveyed our department to identify diagnoses that place patients at risk for infertility and barriers to formalized fertility consultations. We then provided educational sessions to address these barriers with pre- and post-evaluation to measure efficacy. Our longitudinal assessment, encompassing multiple points of intervention, was compared to results from previous chart review (2010-2013). Results: Of 474 patients diagnosed between 2014-2020, 175 (90 females, 85 males) warranted a fertility discussion per inclusion criteria. 61 (67.8%) females received a fertility discussion and of those 8 (8.9%) completed oocyte or gonadal tissue preservation, all between 2017-2020. 52 (61.2%) males received a fertility discussion and 20 (23.5%) completed sperm cryopreservation, with even distribution pattern between 2014-2020. Following implementation of an electronic fertility consult process and standardized fertility preservation documentation, there was an increase in documented fertility discussions from 30% in 2014 to 63.6% in 2020. Internal department survey responses identified a lack of comfort with knowing fertility preservation options available and diagnoses that should prompt this conversation. Education sessions with pre- and post-provider assessment demonstrated more comfort discussing fertility preservation (average score increase from 3.44 to 4.33) and knowledge regarding diagnoses at higher risk of infertility (average score increase from 3.67 to 4.33). Conclusions: Integration of a standardized fertility preservation process and addressing barriers identified within our division have led to a 33.6% increase in fertility discussions over the last 6 years. While the data shows a promising increase in oocyte and ovarian tissue preservation, sperm banking completion rates remained unchanged. Further steps include incorporation of an automated fertility consultation order into electronic chemotherapy orders, hospital-wide identification of other high-risk patient populations, and continued education of patient, families, and the health care team.

Could the COVID-19 infection have a better prognosis than expected in pediatric hematology oncology and bone marrow transplant patients?

Could the COVID-19 infection have a better prognosis than expected in pediatric hematology oncology and bone marrow transplant patients?

Delirium documentation in hospitalized pediatric patients with cancer.

Screening tools for delirium are being used more consistently in pediatric critical care. However, screening is not universal, and delirium may be underdiagnosed, misdiagnosed, or undocumented in hospitalized patients. We evaluated the identification and documentation of delirium in pediatric oncology and bone marrow transplant patients. A retrospective chart review on all hospitalized pediatric oncology and bone marrow transplant patients admitted to an Academic Cancer center between 2013 and 2016. Patients aged less than 21 years of age with active cancer were included. Patients with major psychiatric conditions, developmental delays, or autism were excluded. Data were collected to characterize documentation concerning the identification and diagnosis of delirium. Of 201 hospitalization records, 54 (26.9%) admissions from 109 unique patients had documentation of delirium. The overall documented incidence of delirium was 3.2% of hospitalizations or 8.2% of unique patients. Patients prescribed opioids and benzodiazepines were more likely to have documentation of delirium. ICD coding under-reported delirium while physician documentation was inaccurate in 26% (53/201) when compared with the chart review. Delirium was frequently undocumented or miscoded. Implementing a validated, universal screening tool for delirium may improve identification and clinical outcomes.

Youth and Pet Survivors: Exploring the Experiences of Pediatric Oncology and Bone Marrow Transplant Patients in a Virtual Animal-Assisted Therapy Pen Pal Program

Introduction: YAPS™ (Youth and Pet Survivors™) is a form of virtual animal-assisted therapy (AAT), a pen pal program designed for children and adolescents with cancer and/or having a bone marrow transplant (BMT) to engage in virtual visits with a dog or a cat (who has also been treated for cancer or serious medical illness) through letter writing and pictures. The purpose of this qualitative descriptive study was to explore the experiences of YAPS participants over time and to explore how virtual AAT may be an additional or alternative intervention to the traditional form of AAT, which involves live visits with animals, primarily dogs. Method: Open-ended, face-to-face interviews were conducted throughout the participants' involvement with their animal pen pal. Interviews were digitally recorded. Data were analyzed using a content analysis method. Results: Fifteen children and adolescents, aged 7 to 16 years, participated. Three main themes and five subthemes were found, including connection, shared experience, and friendship. Themes suggested that a virtual AAT letter writing program can provide a source of fun and a way to process the cancer experience with a dog or cat pen pal who has also faced cancer or serious medical treatment. Discussion: Interventions that promote well-being for pediatric oncology and BMT patients are needed, and virtual AAT seems to be one such intervention suited for those who have an affinity for animals and enjoy letter writing. The findings of this study also presented an exciting and intriguing gap for further research in virtual AAT.

Improving Occupational Performance in Pediatric Hematopoietic Cell Transplant Recipients.

There is a critical gap in the literature regarding the efficacy of occupational therapy interventions for pediatric hematopoietic cell transplantation (HCT) patients. To demonstrate that occupational therapy 4-5×/wk during inpatient hospitalization positively affects strength, coordination, and independence in activities of daily living (ADLs) of pediatric patients during HCT. Retrospective study. Inpatient bone marrow transplant unit at a children's hospital. Thirty-two pediatric patients admitted for HCT. Patients were seen by an occupational therapist as part of an interdisciplinary program. Interventions included play and leisure engagement, upper extremity therapeutic exercises, fine motor activities, and ADL training. Strength, coordination, and daily living skills data were documented prospectively and analyzed retrospectively to compare differences between patients seen by occupational therapy at high versus low frequency. For grip strength (dynamometer), fine motor dexterity (the 9-Hole Peg Test), and independence in ADLs (an ADL functional measure and the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test Daily Activities), the high-frequency group had a significantly smaller decrease in performance from time of admission at pretransplant (baseline) to peak decline after transplant. Grip strength and ADL scores for the high-frequency group returned to baseline at time of discharge more readily than for the low-frequency group. Participation in occupational therapy 4-5×/wk had positive effects on strength, coordination, and independence in ADLs for patients undergoing HCT. This article provides evidence that occupational therapists are an important part of the interdisciplinary team treating pediatric bone marrow transplant patients. It also demonstrates that occupational therapy interventions delivered at a high frequency can have a positive impact on upper extremity strength and independence in ADLs.

Impact of hospital acquired infections on post-transplant one year mortality in pediatric bone marrow transplant patients

Children undergoing hematopoietic stem cell transplant (HSCT) are prone to infections, especially when hospitalized for the transplant or additional medical care. These infections are perceived to increase patient's mortality risk, but data are lacking. We conducted this study to assess the burden and the impact of hospital acquired infections (HAI) on mortality risk among pediatric HSCT patients. This retrospective study included 169 patients that received allogeneic HSCT between January 1 2011 and July 6 2017 at Children's National Hospital, a tertiary referral center. Clinical and laboratory data were reviewed for 1 year after transplant to determine HAI and survival status. The HAI incident rates stratified by bloodstream, respiratory, and gastrointestinal infections were then compared between deceased patients and survivors. Including transplant, 169 patients sustained 499 hospital admissions for total of 10,523 patient days and 112 HAI episodes, resulting in a HAI rate of 10.6 per 1,000 patient-days. Within 1-year after transplant, 38 (22%) patient died, 30 (17.5%) with nonrelapse-related causes. Unadjusted univariate analysis revealed mortality correlated with cell source (p=0.035), donor type (p = 0.002), respiratory viral infections (P = .015), and central line associated blood stream infection (CLABSIs; P < .001). Adjusted analysis revealed CLABSI and respiratory adenovirus infection independently increased mortality risk by 3-fold (hazard ratio: 3.22, 95% confidence interval:1.30-8.00) and (hazard ratio: 3.32, 95% confidence interval: 1.22-9.06), respectively. In light of the high frequency of multiple factors contributing to mortality we are unable to determine the degree HAI contributed mortality. However, our findings suggest preventing CLABSIs and respiratory adenovirus infections are crucial to improve the 1-year survival among pediatric HSCT patients.

Clinical Utility of Anaerobic and Fungal Blood Cultures in the Pediatric Oncologic Population.

If there is a concern for sepsis in a pediatric patient an aerobic blood culture is obtained. A febrile or ill oncology patient will often be evaluated with aerobic, anaerobic, and fungal blood cultures. There is to our knowledge little evidence to confirm the added benefit of broadly obtaining these cultures. A retrospective analysis of blood cultures from patients in the oncology and hematopoietic stem cell transplant wards at Children's National Medical Center between January 2010 and April 2017. Positive anaerobic and fungal cultures were evaluated for corollary positive aerobic cultures from the same time frame (+/-24 h). Unique isolates were designated as those positive anaerobic and fungal cultures without positive aerobic cultures and evaluated with detailed chart review. A total of 10,950 cultures were evaluated during the study period: 6579 aerobic, 2391 anaerobic cultures, 1980 fungal. In total, 419 positive aerobic, 140 positive anaerobic, and 43 positive fungal cultures were reviewed. Among these, 22 unique anaerobic cultures and 21 unique fungal cultures met case criteria. Only 7 cultures of obligate anaerobes were observed: 4 Clostridial spp., 2 Propionobacterium acnes, and 1 Peptostreptococcus spp. Thirteen of 21 fungal isolates consisted of a single colony and were regarded as probable contaminants. Penicillium, Cladosporium, and dematiaceous molds were in greatest frequency. Potential risk factors for patients with breakthrough isolates were evaluated and described. There is little increased yield from the use fungal and anaerobic blood cultures in addition to aerobic blood cultures in the routine evaluation of pediatric oncology and bone marrow transplant patients. Fungal and anaerobic blood cultures and should be reserved for cases with high clinical suspicion.

Planning for Success: A Multidisciplinary Approach to Complex Discharges in Pediatric Blood and Marrow Transplant

Topic Significance & Study Purpose/Background/Rationale The discharge process for the pediatric bone marrow transplant patients is very complex. It is overwhelming for both the patient and their caregiver as they struggle to learn about infections, precautions, medication administration, dietary restrictions, social isolation, and when and whom to call in the event of a fever or other medical emergency. Although patients look forward to leaving the hospital after a tenuous inpatient stay, the care remains very multifaceted and informational needs are high at the time of discharge. We have developed a pathway that eases the stressors of discharge for families and helps the team provide individualized support specific to their needs. As a team we can anticipate those needs and ensure a successful transition to home. Methods, Intervention, & Analysis Preparation starts early with education provided prior to admission and is reinforced repetitively during their inpatient stay. The multidisciplinary team who collaborate with discharge planning include providers, pharmacists, social workers, case managers, nurses, and nutritionists. The role of each team member is explained and they are present at a discharge meeting that is scheduled with the family upon the patient showing first signs of engraftment and clinical stability. Those members are then expected to follow-up as needed with each patient prior to discharge. A discharge roadmap and checklist is used and may be modified based on additional needs of individual patients. Key elements of the discharge pathway reviewed at the discharge meeting include: clinical eligibility for discharge completed by the provider, medication review completed by BMT Pharmacist and Case Manager, transition to home completed by Acute Care Nurse Coordinator, and ensuring appropriate resources are utilized while identifying potential barriers completed by the BMT Social Worker. Findings & Interpretation This pathway has streamlined the discharge process by decreasing medication errors and improving medication compliance, establishing effective communication among the team and to patients and their caregivers, setting clear expectations for patients in the outpatient setting. Discussion & Implications This pathway can help other Pediatric Blood and Marrow Transplant Centers in reorganizing the discharge process to improve quality of care and outcomes.

An Institutional Approach to Enhance Caregiver Discharge Education on a High Acuity Pediatric Bone Marrow Transplant Care Unit

Topic Significance & Study Purpose/Background/Rationale Preparing patients and families for transition from hospital based care to home care is crucial. This transition has a variety of implications for pediatric bone marrow transplant patients and their caregivers. These patients experience lengthy hospitalizations due to the complexity of their care which creates a challenging and stressful environment for the role of the caregiver. There has been a movement toward shorter lengths of hospital stay to reduce healthcare costs which result in patients being discharged home in increasingly short periods of time (Heine, Kock, & Goldie, 2004; Weiss et al., 2017). Nurses play a key role in providing education and are responsible for detailed, concise discharge teaching. Due to patients being discharged earlier post-transplant, our institution recognized the need to develop standardized focused discharge teaching classes offered in English and Spanish. Our goal is to help decrease hospital readmission rates and increase patient satisfaction in the area of nursing education. Methods, Intervention, & Analysis The BMT clinical educator and colleague consulted with the leadership team. A collaborated approach was used to develop family-oriented BMT discharge teaching classes. Classes began weekly in February 2019. If families could not attend the scheduled classes, tailored individual classes were provided to the caregivers. Attendees were asked to complete an evaluation form. This form is used to demonstrate parental satisfaction with the discharge education provided by the Bone Marrow Transplant nursing staff. Findings & Interpretation Overall, the impact of discharge classes has demonstrated a positive effect on pediatric BMT caregivers and their families. Our BMT unit patient experience scores have increased by 13.2% in fiscal year 2019. Discussion & Implications One implication noted is that our classes have not measured the caregiver's perspective on readiness for discharge. In the future, we aim to measure this by using the Readiness for Hospital Discharge Scale (RHDS). According to literature review, studies suggest evidence that parent perception of readiness for hospital discharge is influenced by predischarge hospital care processes including care coordination and discharge teaching for parents (Lerret, et al., 2015). By providing structured discharge teaching classes and future use of validated scales, our institution will be one step further in providing successful nursing discharge education.

1778. Epstein–Barr Virus Genetic Diversity: Evaluation of BZLF1 Variants among Bone Marrow Transplant Patients and Individuals with Infectious Mononucleosis

BackgroundEpstein–Barr virus (EBV) is associated with several diseases, including infectious mononucleosis (IM) and malignant disorders, including post-transplant lymphoproliferative disorder (PTLD). The relationship between strains of the virus and disease manifestations or illness severity is of interest. Such strains have been defined by genetic variations in the major viral genes. Data involving the patterns of genetic diversity of the virus in different populations are required. We examined the genetic diversity of the BZLF1 gene, which is a major lytic gene of the virus.MethodsWe sequenced the BZLF1 gene of EBV following amplification from DNA that was extracted from blood obtained from pediatric bone marrow transplant (BMT) patients and children and young adults with IM. Sequencing was done by Sanger methodology (dideoxy DNA sequencing) and the sequences were aligned with a reference strain of EBV using Geneious software. The variant burden and types of single nucleotide variants (SNV) were compared across the 3 exons of the BZLF1 gene.ResultsWe sequenced the BZLF1 gene using 21 patients with IM (median age 14, age range 2–19 years) and 11 who underwent bone marrow transplantation (median age 6, range 3–13 years). Three of 11 BMT patients developed post-transplant lymphoproliferative disorder (PTLD). Among the 3 exons, exon 1 had the greatest diversity across both study groups. There was a tendency for less diversity among PTLD samples, with no sample containing >1 single nucleotide variant (SNV) in contrast to the other samples. In samples that contained SNVs, there was a non-statistically significant trend for more SNVs to occur among the IM samples compared with PTLD samples (median 4.5 and 0, respectively; P > 0.05). Additionally, 2/11 (18.2%) BMT sequences contained more than 1 SNV compared with 7/21 (33.3%) IM sequences (P > 0.05).ConclusionThere was a tendency for more genetic diversity among samples from patients with IM compared with bone marrow transplant patients, notably those with PTLD. Further studies will determine if this tendency is due to selective pressures in the transplant setting, including but not limited to the use of antiviral agents directed at the lytic phase of EBV.Disclosures All authors: No reported disclosures.